Despite advances, more work left to do in cervical cancer prevention

More than 40 years ago, cervical cancer was the leading cause of cancer death in women in the United States. Now, cervical cancer is ranked only 14th in cancer incidence and even lower in cancer-based mortality statistics. The most recent data provided by the Centers for Disease Control and Prevention shows that in 2010, 11,818 women were diagnosed with cervical cancer and only 3,939 women died from their disease. This dramatic success is even more poignant when we realize that cervical cancer remains the number one cause of cancer death in women worldwide.

The largest contributing factor in reducing the incidence of cervical cancer was the introduction of the Pap tests in the 1950s. The National Cancer Institute reported that the implementation of this screening test was solely responsible for decreasing both the incidence and the mortality of cervical cancer by 60% between the years of 1955 and 1992. The Pap test detects early precancerous lesions that can be treated to effectively prevent the progression to malignancy.

More than half of U.S. women currently diagnosed with cervical cancer report never having had a prior Pap test performed. Many of the remaining women have not had a Pap test within the last five to 10 years, or if they have had a recent Pap test, they have failed to undergo the appropriate follow-up or treatment.

The second wave of advancement came in the 1980s when scientific studies finally confirmed the association between cervical cancer and HPV. We now know that more than 99% of cervical cancers are caused by 13 high-risk strains of HPV. This realization has led to a flood of data that has not only led to advancements in understanding the disease overall but has led to dynamic changes in how we screen, prevent and treat cervical cancer. Within the US alone, this greater knowledge has dramatically changed how we use the Pap test. For example, we know that young women who get the HPV vaccine are more likely to clear HPV infections and are less likely to have progression of HPV-related disease. Therefore the newest guidelines recommend not collecting a Pap test until a woman is at least 21 years old.

Co-testing (collection of Pap test and testing for the presence of high-risk HPV subtypes) in women aged 30 years and older has allowed us to spread out the collection of Pap tests to three- to- five-year intervals. These important revisions in screening guidelines have not only reduced unnecessary exams and procedures, but they have decreased the cost of being able to provide excellent preventative health care. Despite current guidelines, many women in the US still do not have access to health care. Of those women who do get a Pap test, many are still not appropriately educated on or treated along these recommendations.

The other major recent addition has been the development of the HPV vaccine, which prevents the cancer from ever happening. However, the implementation of the HPV vaccine is having a less successful start than the Pap test. The Center for Disease Control and Prevention survey found that only about 28% of females received the HPV vaccination in 2012. This was even lower in the adolescent males surveyed. The expected benchmark in both females and males is at least 80% by the year 2020. In a country where the majority of other adolescent vaccinations are being successfully administered, there is clearly a need for improvement. Vaccinations hold the most significant promise for disease prevention.

No other gynecologic cancer has had this type of advancement. Maybe the success has unintentionally distracted us from the work that still needs to be done. We need to find ways to effectively educate and encourage our health care colleagues to comply with Pap test screening guidelines and to vaccinate our children. This is imperative not only for cancer prevention, but for our ability to provide sustainable cost-effective health care.